effective communication in building a culture of compliance€¦ · caron wingerchuk senior...

CARON WINGERCHUK

Senior Director, Pharmacy Solutions

BETH MATEL

Senior Director, Compliance Solutions

EFFECTIVE COMMUNICATION IN BUILDING A CULTURE OF COMPLIANCE

Copyright © 2018 Gorman Health Group2

Direct Takeaways

Effective Communication Can Inspire Motivation and Action

How You Can Begin to Build a Culture of Compliance Beginning With Your “C-Suite”

Enforcement of Compliance Standards and Resulting Disciplinary Actions

Keeping a Close Eye on Your Progress Toward Implementing Corrections


EFFECTIVE COMMUNICATION

COMPLETENESS

CONCRETENESS

COURTESY

CORRECTNESSCLARITY

CONSIDERATION

CONCISENESS




Lack of communication results in tension and uncertainties in the workplace

• Clarity of purpose and execution

• Education

Mental, physical, and behavioral strategies are required for effective communication

• Safe space for reporting (non-retaliation)

• Reward exemplary behaviors

Knowing and understanding individuals requires different forms of treatment and communication

• Communicating with different business units may require different approaches


LESSONS IN THE FIELD

Is your organization structure a hindrance to

effectively communicating to the CEO and/or the Board of Directors (BOD)?


Lessons in the field

Example 1: Organizational Structure

What makes the most sense in your organization?

Compliance Officer

SIU

CTMs

Delegation Oversight

Internal Audit


DO YOU HAVE A PYRAMID PLAN?

*CTMS

*APPEALS

*GRIEVANCES

*CUSTOMER SERVICE

*Impacts Star Ratings measures



Example 2: Leadership Support

You have executive leadership who do not appear to support your compliance goals.

What do you do?


COMPLIANCE MARKETINGASK YOUR CEO TO…

Draft the opening for your Compliance newsletter

Attend your annual “Compliance Week” activities

Write a blog about the importance of compliance


“The less people know, the more they yell.”– Seth Godin

EFFECTIVE COMMUNICATION CAN INSPIRE MOTIVATION AND ACTION

•Be aware of barriers

•Don’t overwhelm with too much detail

•Ensure your message is concise



Example 3: Cover-Ups

Do you have staff undermining compliance standards? “Cover your butt” mentality?



Example 3

Anti-retaliation may not be as obvious as one thinks

• Firing/Demotion

• Intimidation/Threats

• Isolating, mocking, or false accusations

A proactive anti-retaliation program is designed to:

• Receive and respond appropriately to employees’ compliance concerns

• Without an effective program, problems may go unreported

• Fear of retaliation or feeling frustration over the lack of effective resolution of concerns

System for listening to and resolving employees’ concerns

• Senior management (e.g., CEO and BOD) should lead by example


Require training for all managers to make certain they understand what retaliation is

Communicate the organizational benefits of anti-retaliation practices and what it takes

programmatically to prevent retaliation

Ensure there is a mechanism for accurately evaluating employees’ willingness to report concerns

and the actual record in preventing retaliation against employees who report

If appropriate, communicate publicly recognizing the contribution of employees whose

disclosures have made a positive difference to the organization

Perhaps through an award that is publicized company-wide

Of course, taking into account an employee’s preference for confidentiality

Effective communication and information dissemination is key




Example 4: It’s Not a Big Deal

Have you had departments handle issues without reporting to Compliance?

Nothing is too small – report and leave it to Compliance to determine next steps.



Example 5: Vendor Communication

Have you had challenges with your FDRs?

Been surprised with how a vendor (PBM) was actually servicing their members vs. how you thought they were?



Communication with the PBM, Pharmacy, SIU

Quarterly meeting to discuss PBM FWA reports and investigation referrals

Designated RPh to serve as fraud liaison for SIU



Example 6: Keeping It All Together

Have you experienced a situation where compliance was compromised due to a lack of resources?


Resources

Financial People Technology


DASHBOARD REPORTS


•Should contain measurable CMS metrics

•Data must be verified

•Draw attention to those items improved

DASHBOARDS – THEY REALLY DO MATTER!



Example 7

It’s time for enforcing your disciplinary standards and taking corrective action.

Do you have senior management’s buy-in?


Civil Money Penalties (CMPs)

• Failure to comply with Medicare requirements related to Part D formulary and benefits administration and coverage determinations, appeals, and grievances

• IRE auto-forward outlier

• Failure to provide Medicare enrollees with medical services and prescription drug benefits in accordance with Medicare requirements

WHY IS COMPLIANCE IMPORTANT?What Consequences Are Meaningful?


CMS protocols – universes

Continuous improvement

Adjusting as needed

Monitoring progress

PROGRESS TOWARD IMPLEMENTING CORRECTIONS

Communicating progress


STRATEGIES FOR CONSIDERATION

Encourage visibility from leaders to all levels within organization

Communication = Education

Face-to-face meetings

Establish regular communication channels with business owners/ stakeholders/FDRs

Educate at all levels


STRATEGIES FOR CONSIDERATION

↘ Communication = Education

↘ Educate at all levels • Encourage visibility from leaders to all levels within organization

↘ Establish regular communication channels with business owners/ stakeholders/FDRs• Face-to-face meetings

↘ Simplify• Streamline documentation

• Utilize technology

↘ Understand what your colleagues do• Reasonable turnaround times for requests

↘ Re-audit/Test for closure


WHO IS GORMAN HEALTH GROUP?Gorman Health Group is the leading solutions and consulting firm

for government-sponsored health programs

Government ProgramsLeading enterprise of national consulting services and software solutions for payers and providers

Our MissionOur mission, as the industry’s most active professional services consultancy and provider of technology-based solutions, is to empower health plans and providers to deliver higher quality care to beneficiaries at lower costs while serving as valued, trusted partners to government health agencies

Washington, DCHeadquartered in Washington, DC, with more than 200 staff and contractors nationwide with over 2,000 combined years of Government Programs experience

LeadershipDeep payer and provider knowledge coupled with Centers for Medicare & Medicaid Services (CMS) regulatory expertise


Our clients have one-stop access to expert advice, guidance, and support, in every strategic and operational area for government-sponsored programs, across eight verticals

CLINICALPairing clinical teams with innovation to provide patient-centered care

PROVIDER STRATEGIESSupporting network design and medical cost control implementation

OPERATIONSBringing excellence to every aspect of your implementation — from enrollment to claims payment

COMPLIANCEOffering guidance and support in every strategic and operational area to ensure alignment with CMS

PHARMACYLeading experts in Part D, Pharmacy Benefit Manager, formulary, and pharmacy programs

HEALTHCARE ANALYTICS &

RISK ADJUSTMENT SOLUTIONSImplementing cross-functional risk adjustment programs for medical trend management and quality improvement

SALES, MARKETING & STRATEGYDriving profitable growth and member retention through strategic marketing, sales, and product development

BROAD SERVICES

STAR RATINGS & QUALITY INNOVATIONSStrategic innovations to drive quality and improve

performance


Gorman Health Group (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance

Exchange opportunities. Since 1996, our unparalleled teams of subject matter experts, former health plan executives, and seasoned healthcare regulators have been providing strategic,

operational, financial, and clinical services to the industry across a full spectrum of business needs. Our mission is to empower health plans and providers, through a compliant, member-centric

focus, to deliver higher quality care to members at lower costs while serving as valued, trusted partners.

Further, our software solutions have continued to place efficient and compliant operations within our clients’ reach. Our Valencia™ software provides rigorous, compliant, and transparent

workflow controls that ensure your operational processes – and the resulting payment– are as accurate as possible. Sentinel Elite™ is our module-based software solution designed to assist

government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Our Online Monitoring Tool™

(OMT) is the complete Medicare Advantage and Part D compliance toolkit, designed to perform ongoing monitoring and auditing, manage regulatory notices, document corrective actions, and

streamline member material review. CaseIQ™ brings clarity to appeals and grievances and offers a new way to ensure your cases come to a compliant resolution. We also offer training courses

on a variety of industry topics designed to meet the unique needs of your organization through Gorman University™, and our exclusive daily digest, The Insider, provides in-depth analysis and

expert summaries of the most critical legislative and political activities impacting and shaping your organization.

Stay connected to industry news and gain perspective on how to navigate the latest issues by subscribing to our weekly newsletter, and follow us on LinkedIn, Facebook, and Twitter.

We are your partner in government-sponsored health programs.

T

E

T

E

Caron Wingerchuk, PharmD, BSP

Senior Director, Pharmacy Solutions

(480) 492-3852

[email protected]

Beth Matel, HCP

Senior Director, Compliance Solutions

(520) 237-2508

[email protected]

https://www.gormanhealthgroup.com/subscribe/

https://www.linkedin.com/uas/login?trk=sentinel_org_block&session_redirect=https://www.linkedin.com:443n.com/company/gorman-health-group

https://www.facebook.com/gormanhealth

https://twitter.com/gormanhealth

mailto:[email protected]

mailto:[email protected]

effective communication in building a culture of compliance€¦ · caron wingerchuk senior...

Documents